MEDICARE: DR. LARRY CHARLES PEARSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RR0500X	Rheumatology Physician	21803	WI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	110094338	OTHER	WI	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	387464687004	OTHER	WV	BLUE CROSS/ BLUE SHIELD

General Provider Information

NPI Number	:	1699776237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY CHARLES PEARSON M.D.

Provider Business Mailing Address
First Line	:	601 N BARKER RD
Second Line	:	110
City	:	BROOKFIELD
State	:	WI
Zip	:	53045-5929
Country	:	US
Telephone Number	:	262-785-0777
Fax Number	:	262-785-0610

Provider Business Practice Location Address
First Line	:	601 N BARKER RD
Second Line	:	110
City	:	BROOKFIELD
State	:	WI
Zip	:	53045-5929
Country	:	US
Telephone Number	:	262-785-0777
Fax Number	:	262-785-0610

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2005
Last Update Date	:	10/31/2019

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